APPLICATION FORM FOR APPEARING IN THE DIBRUGARH UNIVERSITY RESEARCH

ADMISSION TEST (DURAT) 2014

Sl. No.


DIBRUGARH UNIVERSITY
Dibrugarh 786 004

Subject:
Applied for Please mark X in the appropriate box
M.Phil Ph.D. Both


1. Name of the candidate in Full:
(BLOCK LETTERS): Surname Name Middle Name
MR./MS.

2. Address for Correspondence with PIN Code and Mobile No.:
________________________________________________________________________

________________________________________________________________________

Pin___________________________ Mobile No. ___________________

3. Fathers Name :

4. Guardians Name, Occupation and Address:
Name________________________________________Occupation_____________________
Address_____________________________________________________________________
_____________________________________________Pin_____________________
Mobile No./Telephone No (with STD Code) _____________________________________________

5. Mothers Name : ..

6. Date of Birth: Day Month Year
(According to the Certificate)

7. Nationality: ..

8. Sex: (Please tick /) Male Female

9. Caste (Please tick/)
(Attach Certificate)






To be submitted to the concerned Teaching
Department/ Centre of Studies on or before
24.10.2014


Affix passport
size
photograph
here



SC ST(P) ST(H) OBC GENERAL

10. Whether differently abled: Yes No
(If yes, please state the Nature of the Handicap and attach Medical certificate issued by the Joint Director of Health Services of the
District concerned)

11. Whether employed? Yes No (if yes, produce No Objection certificate from the Employer)

12. Educational Qualification (Please attach self attested Pass Certificate and Marksheet):
Post Graduate
Or Equivalent Degree
Subject
University/
Institute
Roll No. Year of
Passing
Class Percentage of
Marks/CGPA




13. Give particulars of submission of Examination Fee:
N.B.: The candidates shall have to deposit Rs.500.00/- (Rupees Five Hundred) + Rs.60/- (Rupees Sixty) only as
Examination Fee+ Bank Charge at the Account of the State Bank of India mentioned in the prescribed
Bank Challan, which can be tendered through any Branch of the State Bank of India. Prescribed copies of
the Bank Challan are available with this Application Form. It may kindly be noted that the University shall
not receive the Fees in any other form.

(a) Fee Deposited Bank Challan No.

(c) Amount: Rs. (d) Date of Issue:



DECLARATION
I declare that the information given above is true and complete to the best of my knowledge and
belief and if any of them is found to be incorrect, my admission shall be liable to be cancelled and I
shall be liable to such other disciplinary action as may be decided upon by the University.


Date:
Place: Signature of the Candidate

Incomplete Application forms shall be summarily rejected.


DIBRUGARH UNIVERSITY RESEARCH ADMISSION TEST (DURAT), 2014

ATTENDANCE SLIP FOR USE AT THE TEST CENTRE

(TO BE KEPT WITH THE OFFICER-IN-CHARGE FOR USE ON THE DAY OF EXAMINATION)

NAME__________________________________ Subject:________________________

Applied for
(Please mark X in the appropriate box)
M.Phil Ph.D. Both


Roll No.



Date of Test : 15.11.2014
Time : 11.00- 14 Hours



Signature of the Candidate Signature of the Head/ Director of the Department/ Centre of Studies


----------------------------------------------------------------------------------------------------------------------


DIBRUGARH UNIVERSITY RESEARCH ADMISSION TEST (DURAT), 2014
ADMIT CARD

Applied for
(Please mark X in the appropriate box)
M.Phil Ph.D. Both


Name of the Candidate____________________________________________

Fathers / Mothers Name___________________________________________

Address for Correspondence _____________________________________
___________________________________________________________
________________________________ PIN

Date of Test : 15.11.2014
Time : 11.00- 14.00 Hours






Signature of the Candidate Signature of the Head/ Director of the Department/ Centre of Studies


*Admit Card shall not be sent by post. The candidates shall have to collect it from the Teaching Department/ Centre of Studies concerned.




Please
Affix
passport
size
photograph
Roll No.


Please
Affix
Passport size
Photograph